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Pain: strong opioid use (MSK)
GID-IND10346: The percentage of patients with chronic musculoskeletal pain prescribed strong opioids in the preceding 12 months.
Indicator type
General practice indicator suitable for use in the QOF.
Rationale
This indicator aims to prevent harm from the overuse of strong opioid medicines for conditions in which they are not recommended. The intention of the indicator is to reduce prescribing of strong opioids therefore a lower value would equal better achievement.
Opioids have the potential for harm, including gastrointestinal and central nervous system adverse events as well as physical dependence, opioid-induced hyperalgesia and tolerance. Other non-pharmacological and pharmacological treatments are more effective in people with chronic musculoskeletal pain.
Source guidance
Osteoarthritis in over 16s: diagnosis and management. NICE guideline NG226 (2022), recommendation 1.4.6.
Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. NICE guideline NG193 (2021), recommendation 1.2.10
Low back pain and sciatica in over 16s: assessment and management. NICE guideline NG59 (2016, updated 2020), recommendations 1.2.17 and 1.2.28
Specification
Numerator: The number of patients in the denominator prescribed strong opioids in the preceding 12 months.
Denominator: The number of patients with chronic musculoskeletal pain in the preceding 12 months.
Definitions:
Strong opioids are defined as those described in the BNF treatment summary for analgesics plus hydromorphone hydrochloride. Combination formulations should be included. All formulations and all routes of administration should be included. The date of a prescription for a strong opioid must come after the date of the relevant diagnosis code.
Chronic musculoskeletal pain is defined as 2 records of the same musculoskeletal pain code more than 3 months apart.
The CPRD data request Exclusions:
Patients with palliative indications (based on the palliative care register).
Patients with opioid dependence who are prescribed methadone or buprenorphine for this indication will be excluded. All medicines for opioid dependence listed under BNF section 4.10.3 will not be included in the numerator.
Question for consultation:
9. Should the population for this indicator be limited to adults (ages 18 and over)?
NICE is currently testing the construction of the indicator using a primary care research database, in particular, the appropriateness of using musculoskeletal (MSK) codes more than 3 months apart.
10. Should the time window between musculoskeletal pain codes have an upper limit? For example, is it reasonable to assume chronic pain if the 2 codes are 11 months apart?
11. Is searching for the same musculoskeletal pain code more than 3 months apart too restrictive? For example, this would exclude a patient who has a code for hip arthritis in month 1 and a code for knee arthritis in month 4.
12. Is it likely that people with musculoskeletal pain will be prescribed opioids for other reasons?
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